The amendment to Rule 59G-1.040 clarifies Florida’s Pre-Admission Screening and Resident Review (PASRR) process including the addition of information regarding the resident review process.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Division of Medicaid

Bureau of Medicaid Policy

RULE NO.:RULE TITLE:

59G-1.040Pre-Admission Screening and Resident Review

PURPOSE AND EFFECT: The amendment to Rule 59G-1.040, F.A.C. clarifies Florida’s Pre-Admission Screening and Resident Review (PASRR) process including the addition of information regarding the resident review process.

SUBJECT AREA TO BE ADDRESSED: Pre-Admission Screening and Resident Review.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-1.040, Florida Administrative Code, will have as provided for under Sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.902, 409.905(8), 409.912 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME, AND PLACE SHOWN BELOW:

DATE AND TIME: September 10, 2015, 1:00p.m. ‒ 2:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room C, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any persons requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Monty McCullough. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Monty McCullough, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]. Comments will be received until 5:00 p.m., on September 10, 2015

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-1.040 Pre-Admission Screening and Resident Review.

(1) Purpose.

(a) The Pre-Admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Social Security Act (SSA), Title 42, Code of Federal Regulations (CFR), Sections 483.100 through 483.138, Subpart C., Sections 483.100 through 483.138, Code of Federal Regulations. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with a diagnosis of or suspicion of serious mental illness or intellectual disabilities, or related conditions, are identified and admitted or allowed to remain in the nursing facility only if there is a verified need for such services.

(b) The Pre-Admission Screening and Resident Review is intended to ensure that individuals who are being considered for placement in a Medicaid-certified nursing facility (NF) or residents who experience a change in condition are:

1. Evaluated for serious mental illness (SMI) and intellectual disability or related conditions (ID).

2. Offered the most appropriate setting for their long-term care needs (including the determination of whether NF level of services is considered appropriate).

3. Able to receive specialized services, if indicated.

(c)(b) The Pre-Admission Screening and Resident Review PASRR is required for all applicants to an NF Medicaid-certified nursing facilities, regardless of payer payor.

(2) Definitions.

(a) Adult(s) – Individuals who are age 21 years and older.

(b) Agency for Health Care Administration (AHCA) – The single state agency responsible for the Florida Medicaid program under Title XIX of the SSA and for oversight of the PASRR program in Florida.

(c)(b) Agency for Persons with Disabilities (APD) – The Florida aAgency that for Persons with Disabilities works in partnership with local communities to support persons with developmental disabilities as defined in section 393.063, Florida Statutes (F.S.). in living, learning and working in their communities. APD serves Floridians with autism, cerebral palsy, Down syndrome, intellectual disabilities, Prader-Willi syndrome, and spina bifida. APD is responsible for completing the Pre-Admission Screening and Resident Review (PASRR) Level II evaluations and determinations for intellectual disabilities (ID) or related conditions.

(d)(c) Comprehensive Assessment and Review for Long-Term Care Services (CARES) – Program operated by tThe Florida Department of Elder Affairs (DOEA)’ that conducts Florida’s long-term care screening and assessment processes for adults. Comprehensive Assessment and Review for Long-Term Care Services program.

(e)(d)Child(ren) – Individuals who are under the age of 21 years.

(f)(e) Florida Department of Children and Families (DCF) – The Florida Department of Children and Families (DCF) is the agency in Florida that supports Florida families through a variety of human services programs. such as the DCF Mental Health program and the Automated Community Connection to Economic Self Sufficiency (ACCESS) program. The DCF Mental Health program office or State-designated contracted provider is responsible for completing the Pre-Admission Screening and Resident Review (PASRR) Level II evaluations and determinations for serious mental illness (SMI). ACCESS helps to promote strong and economically self-sufficient communities by providing food, cash and medical assistance to individuals and families on the road to economic recovery. ACCESS is responsible for determining Medicaid eligibility, including eligibility for Medicaid long-term care services.

(g) Florida Department of Health (DOH) – The agency responsible for Florida’s public health, according to section 381.011, F.S.

(h)(f) Intellectual Disability (ID) – As defined in the Social Security Act, Title 42 Subpart C, Section 483.102(b)(3), Code of Federal Regulations, Iindividuals are determined to have ID (mild, moderate, severe, or profound), as defined in the SSA, 42 CFR 483.102(b)(3), Subpart C, according to the criteria in the American Association on Intellectual Disability's Mental Deficiency’s Mmanual on Classification in Intellectual Disability Mental Retardation (1983), incorporated by reference. The American Association on Intellectual Disability's Mental Deficiency’s Mmanual on Classification in Intellectual Disability Mental Retardation (1983) is available for inspection at the Agency for Health Care Administration, Building 3, 2727 Mahan Drive, Tallahassee, Florida 32308. The diagnosis of ID includes related conditions, i.e., individuals who have a severe, chronic disability that meets all of the following conditions:

1. Is attributable to one of the following:

a. Cerebral palsy or epilepsy.; or

b. Any other condition, (other than mental illness), found to be closely related to ID because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons diagnosed with ID, and requires treatment or services similar to those required for these persons.;

2. Is manifested before the person reaches the age of 22 years.;

3. Is likely to continue indefinitely.; and

4. Results in substantial functional limitations in three or more of the following areas of major life activity:

a. Self-care.;

b. Understanding and use of language.;

c. Learning.;

d. Mobility.;

e. Self-direction.; or

f. Capacity for independent living.

(i)(g) Inter-Facility Transfer – The transfer of a resident from one NF nursing facility to another NF nursing facility.

(j)(h) Legal Guardian – The parent(s) for a child of an individual under the age of 18 years, or a person appointed by the courts to exercise the legal rights of the individual who is being evaluated.

(k)(i) Level I PASRR Screen – A process to identify diagnosed or suspected ID, SMI, or both. In general, the Level I screen is based on information gathered by the screener and may include current or prior history of ID or SMI. The Level I PASRR Screen must be completed using the Pre-Admission Screen and Resident Review (PASRR) Level I Screen for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A, __________, incorporated by reference in Rule 59G-1.045, F.A.C. The Agency for Health Care Administration (AHCA), or the entity to which AHCA delegates this responsibility, shall perform the Level I PASRR screening for all children. The CARES program or the entity to which CARES delegates this responsibility shall perform the Level I PASRR screening for all adults. AHCA and CARES will collectively be referred to as the Level I PASRR Screener.

(l) Level II Evaluation and Determination – An in-depth, individualized assessment of the individual to confirm whether the applicant to the NF has SMI, ID, or both; to assess the need for NF services; and evaluate what specialized services, if any, are needed.

(m)(l) Readmission – When aAn individual who is readmitted, within 90 calendar days, to any NF from a hospital to which the individual was originally transferred to by an NF for receiving care.

(j) New Admission – An individual admitted to any nursing facility (NF) for the first time or not admitted as a readmission or not admitted as an inter-facility transfer.

(n) Resident Review (RR) – An evaluation and determination conducted by state designated authorities as described in (9)(b) of this rule when an NF resident experiences a significant change in their physical or mental status. The RR must be completed using the Pre-Admission Screening and Resident Review (PASRR) Resident Review (RR) – Evaluation Request for a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A1, ________, incorporated by reference in Rule 59G-1.045, F.A.C.

(k) Nursing Facility (NF) – A Medicaid-certified nursing facility.

(o)(m) Serious Mental Illness (SMI) – As defined in the SSA Social Security Act, Title 42, CFR 483.102(b)(1), Subpart C, Section 483.102(b)(1), Code of Federal Regulations, an individual is considered to have an SMI, if the individual meets the following requirements related to on diagnosis, level of impairment, and duration of illness:

1. Diagnosis: A major mental disorder that may lead to a chronic disability, identified in under the Diagnostic and Statistical Manual of Mental Disorders (3rd Ed., Revised 1987), incorporated by reference., such as a schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability, The diagnosis of SMI does not include but not a primary diagnosis of dementia, such as including Alzheimer’s disease or a related disorder, or a non-primary diagnosis of dementia, unless the primary diagnosis is a major mental disorder. The Diagnostic and Statistical Manual of Mental Disorders (3rd Ed. R. 1987) is available for inspection at the Agency for Health Care Administration, Building 3, 2727 Mahan Drive, Tallahassee, Florida 32308.

2. Level of Impairment: Functional limitations in major life activities within the past three to six months that would be appropriate for the individual’s developmental stage; an individual typically has at least one of the following characteristics on a continuing or intermittent basis, or is likely to exhibit one of the following characteristics without continued treatment or intervention:

a. Serious difficulty interacting appropriately and communicating effectively with other persons;, a possible history of altercations, evictions, dismissal from employment firing, fear of strangers, or avoidance of interpersonal relationships, and social isolation.;

b. Serious difficulty in sustaining focused attention, inhibiting for long enough to permit the completion of tasks at work or school, commonly found in work settings or in work-like structured activities occurring in school or home settings, manifest difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks.; or

c. Serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction., manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system;

3. Recent Treatment: A treatment history indicating the individual has experienced at least one of the following:

a. Psychiatric treatment more intensive than outpatient care more than once in the past two years (for example, partial hospitalization or inpatient hospitalization).; or

b. Within the last two years, due to the mental disorder, experienced an episode of significant disruption to their the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.

(p)(n) Significant Change – A major decline or improvement in the resident’s status. A major decline in a resident’s status involves changes that require intervention to correct the decline through staff involvement and/or through implementation of standard disease-related clinical interventions that: (i) are anticipated to effect more than one area of the resident’s health status; (ii) requires interdisciplinary review or revision of the care plan; or, both (i) and (ii). A major improvement in a resident’s status involves changes in a resident’s circumstances that: (i) are anticipated to effect more than one area of the resident’s health status; (ii) requires interdisciplinary review or revision of the care plan; or, both (i) and (ii).

(q)(o) Specialized Services – Services that are not covered in the NF per diem and are required for appropriate placement in the NF setting for individuals with ID or SMI whose needs are such that continuous supervision, treatment, and training by qualified mental health or intellectual disability personnel is necessary. Specialized services are specified by the state and, combined with the services provided by the NF, result in continuous and aggressive implementation of an individualized plan of care. Specialized services for ID are directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible, and toward the prevention or deceleration of regression or loss of current optimal functional status, to include behavior analysis services and training services. Specialized services for SMI are utilized to address episodes of mental illness and are rendered at levels required to avert or eliminate the need for acute inpatient psychiatric care.

(3) The Level I PASRR Screens Screener must be notified whenever an individual is referred to an NF for admission.

(a) The Agency for Health Care Administration, or the entity to which AHCA delegates the responsibility, performs the Level I PASRR screens for all individuals seeking admission to, or who are residents of an NF.

(b) The Agency for Health Care Administration delegates the following entities to perform the Level I PASRR screens:

1. The Department of Health for all individuals under the age of 21 years; DOH may not further delegate the Level I screening responsibilities.

2. The CARES program for all individuals age 21 years and older. The CARES program may only delegate the Level I PASRR screen responsibility to hospital and NF staff who are licensed clinical social workers, physicians or registered nurses, licensed mental health counselors, licensed psychologists, or those who hold a Master’s Degree in Social Work.

3. The CARES program and DOH are collectively referred to as the Level I PASRR screener.

(c) The Level I PASRR must be completed by the Level I PASRR screener prior to all admissions to an NF, and within two business days of the request for the Level I PASRR screen, regardless of payment source.

(d) Within the two business days of completion of the Level I PASRR screen, if the individual has a diagnosis of or suspicion of having an SMI, ID, or both:

1. The Level I PASRR screener must send the individual or the legal guardian, as applicable, written notice stating that the individual has a diagnosis of or is suspected of having an SMI, ID, or both, and is being referred for a more in-depth Level II PASRR evaluation.

2. The Level I PASRR screener must also send all of the following documentation for a Level II PASRR evaluation to APD for individuals suspected of having a diagnosis of an ID; or, to the contracted Level II PASRR evaluator for individuals suspected of or having a diagnosis of SMI or both SMI and ID:

a. Completed Pre-Admission Screen and Resident Review (PASRR) Level I Screen for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A, __________, incorporated by reference in Rule 59G-1.045, F.A.C.

(4) Level I PASRR.

(a) A Level I PASRR screening determines whether an individual referred for admission into an NF has or is suspected of having an SMI or an ID diagnosis or related conditions.

(b) A Level I PASRR must be completed for all individuals who are new admissions to an NF regardless of the source of payment.

(c) The Level I PASRR must be completed by the Level I PASRR Screener prior to an individual’s admission to an NF.

(d) Within two days after the Level I PASRR is completed, if the individual has or is suspected of having a diagnosis of SMI and/or ID, the Level I PASRR Screener must send the individual and his or her legal guardian written notice stating that the individual has or is suspected of having SMI and/or ID and is being referred for a more in-depth Level II PASRR evaluation. Within the same two days, the Level I PASRR Screener must also send all of the following documentation to the Agency for Persons with Disabilities (APD) for individuals suspected of having ID, or to the Department of Children and Families (DCF) for individuals suspected of having SMI:

1. Level I PASRR;

b2. Documented informed consent.;

c3. Medical certification for NF or / home and community-based services.;

d4. Other medical documentation including relevant case notes or records of treatment/medication administration record.;

e5. Psychiatric or psychological evaluation, if available.;

f6. An assessment conducted by CARES if the individual is over the age of 21 years. an adult;

g7. An assessment conducted by the DOH Children’s Multidisciplinary Assessment Team (CMAT) if the individual is under the age of 21 years a child.

(f)(e) The Level I PASRR sScreener is responsible for documenting whether the individual is seeking a provisional admission into an NF and the type of provisional admission. They are also responsible for documenting and tracking the appropriate time limits for when a Level II PASRR must be completed for these provisional admissions and making certain that the individual is referred for a Level II PASRR prior to the expiration of the time period.

(4)(5) Level II PASRR, in General.

(a) The Level II PASRR is an in-depth evaluation of the individual and a determination of the need for NF services. If an NF is the most integrated setting appropriate to meet the individual’s long-term care needs, the Level II PASRR must also evaluate what specialized services, if any, are needed for the individual.

(b) All Level II PASRR evaluations are individualized.

(a)(c) A Level II PASRR evaluation is required if the Level I PASRR indicated a diagnosis of or suspicion of SMI, and/or ID, or both. The Level II PASRR and it must be completed under the following circumstances and within the following timeframes:

1. Within seven business days of a Level II PASRR evaluation request, indicating a diagnosis of or suspicion of SMI, ID, or both.

21. In cases of delirium, a Level II PASSR must be completed within seven calendar days after the delirium clears.;

32. For emergency admissions requiring protective services, a Level II PASRR must be completed within seven calendar days of admission.;

43. If the individual does not enter the NF within 30 calendar days of the Level II PASRR evaluation, a new Level II PASRR must be completed prior to admission to the NF.;

54. If the individual enters does not enter the NF within 30 calendar days of the Level II PASRR evaluation, the Level II PASRR must be reviewed and validated prior to admission to the NF.;

65. If an individual with SMI or ID, or both, is transferred to the hospital from the NF and is admitted to the hospital for more than 90 consecutive days, a new PASRR Level II must be completed prior to the individual’s return to the NF.;

76. If there is a significant change in the resident’s mental or physical condition., the nursing facility must notify the Level I PASRR Screener in accordance with 42 USC 1396r, and a new Level II PASRR must be completed;

87. A Level II PASRR must be completed, if If an individual is admitted to an NF for a caregiver’s respite, and remains in the facility longer than a 14 calendar day stay, in advance of the expiration of the 14 days, no more than twice a year. a Level II PASRR must be completed in advance of the expiration of 14 days, if the stay is expected to exceed the 14-day time limit no more than twice a year; or

8. Excluding the above-listed exceptions in 1-7, within seven days of receiving a Level I PASRR indicating a diagnosis or suspicion of SMI and/or ID or a related condition.

(b) Hospital discharge exemptions:

1. Apply to individuals discharged from a hospital into a Medicaid-certified NF, if their stay is expected to last no more than 30 calendar days.

2. Are for individuals who require NF services related to the condition for which he or she was hospitalized; and, the individual’s attending physician has certified, prior to NF admission, that he or she is likely to require less than 30 calendar days of NF services.

(c) If an individual admitted to an NF under the hospital discharge exemption stays in the NF longer than 30 calendar days, any applicable PASRR Level II processes must be completed by calendar day 40. The NF must notify the Level I screener on the 25th day of the individual’s stay to request the Level II PASRR evaluation.

(5) Level II Evaluation Entities and Components.

(a)(d) The following entities are responsible for completion of must complete the Level II PASRR evaluation for individuals referred to an NF or residents referred for an RR, regardless of payer payor:

1. The state-contracted vendor performs the evaluation of DCF for those individuals diagnosed or suspected of having a diagnosis of SMI.;

2. The Agency for Persons with Disabilities APD performs the evaluation and determination for those individuals diagnosed or suspected of having a diagnosis of ID.; and

3. When a Level I PASRR results in a suspicion of both SMI and ID, DCF and APD will coordinate to complete the Level II PASRR.

(b) All PASRR Level II evaluations must involve the following:

1. Individual being evaluated and the legal guardian, if appropriate.

2. Individual’s family, if the individual or the legal guardian agrees to family participation.

(c) The completed Level II PASRR evaluation must be sent to:

1. The PASRR Level I Screener.

2. The evaluated individual or, if appropriate, legal guardian.

3. The admitting or retaining NF, if applicable.

4. The evaluated individual’s attending physician.

5. The discharging hospital, if applicable.

(d) The evaluation may be terminated, according to 42 CFR 483.128, if the evaluator determines at any time during the evaluation that the individual being evaluated either:

1. Does not have SMI or ID.

2. Or,:

a. A primary diagnosis of dementia (including Alzheimer's disease or a related disorder)

b. A non-primary diagnosis of dementia, without a primary diagnosis of SMI, and does not have a diagnosis of ID

(6) Level II PASRR for Individuals with Suspicion of, or Diagnosis of SMI.

(e) The Level II PASRR evaluation must assess the appropriate placement to meet the individual’s needs.

1. In determining appropriate placement, the evaluator must prioritize the individual’s physical and mental needs, taking into account the severity of each condition. The determination of whether an NF is appropriate must include:

a. Evaluation of physical status (for example, diagnoses, date of onset, medical history, and prognosis);

b. Evaluation of mental status (for example, diagnoses, date of onset, medical history, likelihood that the individual may be a danger to self or others); and

c. Functional assessment (ability to perform activities of daily living).

(f) The Level II PASRR must be completed prior to admission to an NF, and it must be issued in the form of a written determination summary report which:

1. Confirms or rules out SMI or ID;

2. Identifies the name and professional title of each person who performed the evaluation(s) and the date on which each portion of the evaluation was administered;

3. Summarizes the medical and social history, including the positive traits, developmental strengths and weaknesses, or developmental or mental health needs of the individual;

4. Identifies whether NF services and specialized services are needed, and identifies any specific SMI or ID services that are required to treat individual needs;

5. If specialized services are not recommended, identifies any specific SMI or ID services that are of a lesser intensity than specialized services;

6. Identifies placement options that are available to the individual, including whether the individual’s needs could be met in a community setting and what services would be needed for the individual to live in such a setting;

7. Documents that the individual and legal guardian, if appropriate, have been educated about all placement options, including information about the benefits of integrated settings, and have addressed any concerns or objections raised by the individual or legal guardian;

8. Includes the basis for the summary report’s conclusions;

9. Notifies the individual and legal guardian of the right to appeal the determination; and

10. Interprets and explains the summary report to the individual and legal guardian.

11. If the Level II PASRR rules out SMI or ID, the screener does not have to complete the items indicated in subparagraphs (5)(f)4.-8.

(g) The completed Level II PASRR evaluation must be sent to:

1. The PASRR Level I Screener;

2. The evaluated individual or, if appropriate, legal guardian;

3. The admitting or retaining NF, if applicable;

4. The evaluated individual’s attending physician; and

5. The discharging hospital, if applicable.

(h) PASRR Level II evaluations must involve:

1. The individual being evaluated, and the legal guardian, if the individual is under age 18, or a legal guardian has been appointed by the courts; and

2. The individual’s family; if the individual or the legal guardian agrees to family participation.

(6) Level II PASRR for Individuals for Whom a Level I PASRR Indicated a Suspicion of SMI.

(a) DCF must ensure completion of the Level II PASRR evaluations for individuals whose Level I PASRR indicated a suspicion of SMI.

(a)(b) A Level II PASRR evaluations and determination for individuals with suspicion of, or diagnosis of an suspected SMI diagnosis must:

1. Confirm or rule out the presence of SMI. A qualified mental health professional must confirm or reject the suspicion of SMI indicated in the Level I PASRR, by reviewing accurate and recent data of a comprehensive history and a physical examination of the person, or performing or ensuring the performance of the same, including:

a. Complete medical history.;

b. Review of all body systems.;

c. Specific evaluation of the person’s neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes.;

d. Additional evaluations conducted by appropriate specialists, where abnormal findings are the basis for an NF placement.;

e. Comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic SMI.;

f. Psychosocial evaluation of the person, including current living arrangements and medical and support systems.; and

g. Comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of SMI functioning, memory functioning, and orientation;, description of current attitudes and overt behaviors;, affect, suicidal or homicidal ideation, paranoia;, and degree of reality testing (presence and content of delusions), and hallucinations.

2. Include a functional assessment of the individual’s ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment must determine whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that an NF placement is required. The functional assessment must address the self-monitoring of health status, self-administering and scheduling of medical treatment, including medication compliance, or both, and self-monitoring of nutritional status;, handling money, dressing appropriately, and grooming.; and

3. Determine the need for specialized services. Specialized services for an SMI diagnosis are:

a. Those services not already covered in the NF per diem.;

b. Services that are utilized to address an episode of mental illness and that are rendered in an NF at levels required to avert or eliminate the need for inpatient psychiatric care.;

c. Developed and supervised by a qualified mental health professional and include one or all of the following:

(I) Psychiatric consultation and evaluation.;

(II) Psychotropic medication management.;

(III) Psychological evaluation.; and/or

(IV) Psychotherapy.

(7) Level II PASRR with for Individuals for Whom a Level I PASRR Indicated a sSuspicion of ID.

(a) APD must ensure completion of the Level II PASRR evaluations for individuals whose Level I PASRR indicated a suspicion of ID.

(a)(b) A Level II PASRR evaluations and determination for individuals with a suspected or diagnosed ID diagnosis must:

1. Confirm or rule out the suspicion or diagnosis of ID.; Aa licensed psychologist must be utilized to identify the intellectual functioning measurement of individuals with ID.;

2. Confirm the need for NF placement.; and

3. Determine the need for specialized services by assessing:

a. The individual’s medical problems.;

b. The level of impact these problems have on the individual’s independent functioning.;

c. All current medications used by the individual, and the current response of the individual to any prescribed medications in the following drug groups:

(I) Hypnotics.;

(II) Antipsychotics (neuroleptics).;

(III) Mood stabilizers and antidepressants.;

(IV) Antianxiety-sedative agents.; and

(V) Anti-Parkinson agents.

d. Self-monitoring of health status.;

e. Self-administering and scheduling of medical treatments.;

f. Self-monitoring of nutritional status.;

g. Self-help development, such as toileting, dressing, grooming, and eating.;

h. Sensorimotor development, such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, hand-eye eye-hand coordination, and extent to which prosthetic, orthotic, corrective, or mechanical supportive devices can improve the individual’s functional capacity.;

i. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which non-oral communication systems can improve the individual's function capacity, auditory functioning, and extent to which amplification devices (e.g. for example, hearing aid) or a program of amplification can improve the individual’s functional capacity.;

j. Social development, such as interpersonal skills, recreation-leisure skills, and relationships with others.;

k. Academic or / educational development, including functional learning skills.;

l. Independent living development, such as meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bed making, care of clothing, and orientation skills (for individuals with visual impairments).;

m. Vocational development, including present vocational skills.;

n. Affective development, such as ability to express emotions;, making judgments, and making independent decisions.; and

o. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).

(b)(c) Specialized services for individuals with ID are:

1. Those services not already covered in the NF per diem.;

2. Behavior analysis services, pursuant to Rule 65G-4.009, F.A.C.;

3. Training services, to include:

a. Services intended to support the participation of recipients in daily, meaningful, valued routines of the community, which for older children and adults may include work-like settings that do not meet the definition of supported employment.; and

b. Training in the activities of daily living, self-advocacy, and adaptive and social skills that are age and culturally appropriate; the service expectation is to achieve the goals defined by each individual or, if appropriate, the individual’s legal guardian; the training, activities, and routine established by the adult day training program must be meaningful to the individual and provide an appropriate level of variation and interest; this training is provided in accordance with a formal implementation plan, developed under the direction of the individual or, if appropriate, the individual’s legal guardian.

(8) The Level II PASRR Determination.

(a) The following entities are responsible for completion of the Level II PASRR determination:

1. The Agency for Persons with Disabilities for those individuals diagnosed or suspected of having a diagnosis of ID.

2. The Department of Children and Families’ Mental Health program office is responsible for completing PASRR Level II determinations for SMI.

3. The Department of Children and Families is the lead agency, in coordination with APD, when the individual has both SMI and ID.

(b) The Level II PASRR determination must be issued in the form of a written summary report which:

1. Confirms or rules out SMI or ID.

2. Identifies the name and professional title of each person who performed the evaluation(s) and the date on which each portion of the evaluation was administered.

3. Summarizes the medical and social history, including the positive traits, developmental strengths and weaknesses, or developmental or mental health needs of the individual.

4. Identifies whether NF services and specialized services are needed, and identifies any specific SMI or ID services that are required to treat individual needs.

5. If specialized services are not recommended, identifies any specific SMI or ID services that are of a lesser intensity than specialized services.

6. Identifies placement options that are available to the individual, including whether the individual’s needs could be met in a community setting and what services would be needed for the individual to live in such a setting.

7. Documents that the individual and legal guardian, if appropriate, have been educated about all placement options, including information about the benefits of integrated settings and that any concerns or objections raised by the individual or legal guardian have been addressed.

8. Includes the basis for the summary report’s conclusions.

9. Notifies the individual and legal guardian of the right to appeal the determination.

10. Interprets and explains the summary report to the individual and legal guardian.

(c) If the Level II PASRR rules out SMI or ID, the state authority does not have to complete the items indicated in subparagraphs (8)(b)4-7 of this section.

(d) The Department of Children and Families or APD must send the completed determination summary to:

1. The evaluated individual and his or her legal representative, as appropriate.

2. The admitting or retaining NF.

3. The individual or resident’s attending physician.

4. The discharging hospital, as appropriate.

(e) The individual or legal guardian must receive notice of the administrative fair hearing process and rights.

(9) Resident Review.

(a) The NF must submit the required documentation to the age appropriate Level I screener and the Resident Review must be conducted promptly, using the Pre-Admission Screening and Resident Review (PASRR) Resident Review (RR) – Evaluation Request for a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A1,_________, incorporated by reference in Rule 59G-1.045, F.A.C. The review must determine whether a change in the resident’s physical or mental condition requires a change in the level of services or continued NF stay.

(b) The NF must notify the state agency responsible for Level I screenings of the necessity of the Resident Review evaluation and determination in accordance with 42 U.S. Code, 1396r.

(10)(8) Nursing Facility NF Residents No Longer Requiring NF Services, but Requiring Specialized Services.

(a) Any NF resident with SMI or ID who no longer requires the level of services provided by an NF, but does require specialized services, and who has continuously resided in an NF for at least 30 consecutive months before the date of determination, may choose to continue to reside in the NF facility or to receive covered services in an alternative, appropriate institutional or non-institutional setting. In consultation with the resident or, if appropriate, the resident’s legal guardian, APD or DCF, as appropriate, must:

1. Inform the resident of the institutional and non-institutional alternatives available for the resident.;

2. Offer the resident the choice of remaining in the facility or receiving covered services in an alternative, appropriate institutional or non-institutional setting.;

3. Clarify the effect on eligibility for services if the resident chooses to leave the facility (including its effect on readmission to the facility).; and

4. Provide for (or arrange for the provision of) such specialized services for the resident’s SMI or ID.

(b) Unless the individual or legal guardian, if appropriate, refuses placement outside the NF, any NF resident with SMI or ID who does not require the level of services provided by an NF but does require specialized services, and who has resided in an NF for less than 30 consecutive months before the date of determination, must be discharged to an appropriate setting where the individual will receive the needed specialized services. In consultation with the resident and, if appropriate the resident’s legal guardian, APD or DCF (as appropriate) must:

1. Arrange for the safe and orderly discharge of the resident from the facility.;

2. Prepare and orient the resident for such discharge.; and

3. Provide for (or arrange for the provision of) such specialized services for the resident’s SMI or ID.

(11)(9) Nursing Facility NF Resident Not Requiring NF Services or Specialized Services.

(a) Unless the individual or legal guardian, if appropriate, refuses placement outside the NF, any NF resident with SMI or ID who does not require the level of services provided by an NF and does not require specialized services, regardless of length of stay, must be discharged. The Agency for Persons with Disabilities APD or DCF (as appropriate) must:

1. Arrange for the safe and orderly discharge of the resident from the facility.; and

2. Prepare and orient the individual for such discharge.

(12) Consent for Level II Evaluation.

(a) All applicants to an NF must be provided a copy of the Level I screen, in accordance with 42 CFR 483.128(a). If a Level II evaluation is required as a result of the Level I screen, the copy of the Level I screen will serve to confirm the request that a Level II evaluation be completed. The signature of the individual being assessed and/or their legal representative, as defined in Rule 59G-1.010, must be obtained, when possible, as acknowledgement and consent for the Level II evaluation. Signing does not mean that the signatory agrees with any treatment(s) or recommendation(s).

(b) The signature is an acknowledgement of the signer’s:

1. Opportunity to participate in decisions regarding the arrangements for continued care.

2. Acknowledgement of verbal and written information regarding the range of services in the assessed individual’s community.

(c) If an individual is not willing, or unable to sign and has no legal representative or health care agent, information regarding the reason for the inability to obtain the signature must be filled in by the Level I screener.

(13)(10) Appeals.(a) The Pre-Admission Screening and Resident Review PASRR determinations that are contrary to the wishes of the individual or legal guardian are appealable through the administrative fair hearing process.

(b) The individual or legal guardian will receive notice of all PASRR determinations along with notice of the administrative fair hearing process and rights.

(14)(11) Records.

(a) Nursing facilities are required to maintain copies of all PASRR screenings, evaluations, and re-evaluations in the resident’s file for the duration of the individual’s stay in the facility and for a period of five years after the resident has been discharged or has been transferred to another facility.

(b) The Level I PASRR sScreener must retain all documentation from the Level I and Level II PASRR screening process for repository.

(15)(12) Oversight. (a) The Agency for Health Care Administration, APD, DCF, and DOEA must enter into memoranda of agreement understanding outlining each respective agency’s role in the PASRR process.

(b) The Level I PASRR Screener must perform a quality assurance review of Level II PASRR screenings to determine compliance with the requirements outlined in this rule, the Social Security Act, Title 42, Subpart C, sections 483.100 through 483.138, Code of Federal Regulations, the Florida Medicaid State Plan, and the executed memorandum of understanding. If deficiencies are found, the Level I PASRR Screener will notify the agency performing the Level II PASRR of the deficiencies. Within five business days of receipt of the notice, the agency will correct all deficiencies and submit an amended Level II PASRR.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905(8), 409.912 FS. History‒New 12-31-13. Amended,______.